Gender identity is one's personal experience of one's own gender. This is generally described as one's private sense of being a man or a woman, consisting primarily of the acceptance of membership into a category of people: male or female.[1] All societies have a set of gender categories that can serve as the basis of the formation of a social identity in relation to other members of society. In most societies, there is a basic division between gender attributes assigned to males and females. In all societies, however, some individuals do not identify with some (or all) of the aspects of gender that are assigned to their biological sex.

In most Western societies, there exists a gender binary, a social dichotomy that enforces conformance to the ideals of masculinity and femininity in all aspects of sex and gender: biological sex, gender identity, and gender expression. Some societies have third gender categories that can be used as a basis for a gender identity by people who are uncomfortable with the gender that is usually associated with their sex; in other societies, membership of any of the gender categories is open to people regardless of their sex.

Gender identity is usually formed by age three and is extremely difficult to change after that.[2][3] The formation also commonly concludes between the ages of four and six.[4] Gender identity is affected by influence of others, social interactions, and a child’s own personal interest. Understanding gender can be broken down into four parts: (1) understanding the concept of gender, (2) learning gender role standards and stereotypes, (3) identifying with parents, and (4) forming gender preference.[5] A three-year-old can identify themselves as a boy or a girl, though they do not yet fully understand the implications of gender.[5]

Gender identity is formed as children search for social cues and display approval for others based upon the gender with which the child identifies, though gender identity is very fluid among young children. Studies suggest that children develop gender identity in three distinct stages: as toddlers and preschoolers, they learn about defined characteristics, which are socialized aspects of gender; the second stage is consolidation, in which identity becomes rigid, around the ages of 5–7 years; after this "peak of rigidity," fluidity returns and socially defined gender roles relax somewhat.[6]

Gender identity, appearance and chromosomes

Although the term gender identity was originally a medical term used to explain sex reassignment surgery to the public,[7] it is most often found in psychology today, often as core gender identity.[8] Although the formation of gender identity is not completely understood, many factors have been suggested as influencing its development. Biological factors that may influence gender identity include pre- and post-natal hormone levels and genetic makeup.[9]

Social factors which may influence gender identity include ideas regarding gender roles conveyed by family, authority figures, mass media, and other influential people in a child's life.[10] Another factor that has a significant role in the process of gender identity is language. There are ways that certain words are associated with specific genders. "The relationship between language and gender has largely reflected how linguistic practices, among other kinds of practices, are used in the construction of social identities relating to issues of masculinity and femininity." (Adegoju,2000).[full citation needed] So children while learning a language learn to separate masculine and feminine characteristics and unconsciously adjust their own behavior to these predetermined roles.[11] Children are often shaped and molded by the people surrounding them by trying to imitate and follow.[12] One's gender identity is also influenced by the social learning theory, which assumes that children develop their gender identity through observing and imitating gender-linked behaviors, and then being rewarded or punished for behaving that way.[13] In some cases, a person's gender identity may be inconsistent with their biological sex characteristics, resulting in individuals dressing and/or behaving in a way which is perceived by others as being outside cultural gender norms; these gender expressions may be described as gender variant or transgender.[14]

Since the development of gender identity is influenced by many factors, it is understandable that there are diagnoses, disorders and conditions associated with it as well. One of the major diagnoses is gender identity disorder (GID). Gender identity disorder is the formal diagnosis to describe persons who experience significant dysphoria (discontent) with the sex they were assigned at birth and/or the gender roles associated with that sex.[15] The Diagnostic and Statistical Manual of Mental Disorders (302.85) has five criteria that must be met before a diagnosis of gender identity disorder can be made. "In gender identity disorder, there is discordance between the natal sex of one's external genitalia and the brain coding of one's gender as masculine or feminine."[7] Interestingly, gender identity disorder is also made up of more specific disorders, each of which focuses on the disorder in people of certain age groups. For example, gender identity disorder in children is specific to children who experience gender dysphoria.

Many people consider themselves to be cisgender, that is, belonging to either the man or woman gender corresponding to their assigned sex of male or female. Before the 20th century, a person's sex would be determined entirely by the appearance of the genitalia, but as chromosomes and genes came to be understood, these were then used to help determine sex. Those defined as women, by sex, have genitalia that are considered female, as well as two X chromosomes; those viewed as men, by sex, are seen as having male genitalia, one X and one Y chromosome. However, some individuals have a combination of these chromosomes, hormones, and genitalia that do not follow the traditional definitions of "men" and "women". In addition, genitalia vary greatly or individuals may have more than one type of genitalia. Also, other bodily attributes related to a person's sex (body shape, facial hair, high or deep voice, etc.) may or may not coincide with the social category, as man or woman. For example, a person with female genitalia, as well as a deep voice and facial hair, may have difficulty determining which gender they identify with. A survey of the research literature from 1955–2000 suggests that as many as one in every hundred individuals may have some intersex characteristic.[16] Intersex phenomena are not unique to humans. In a number of species, even more striking examples exist, for instance the bilateral gynandromorphiczebra finch (half-male, half-female body along its symmetry plane).[17][18]

History and definitions

Conceptual origins

In 1905, Sigmund Freud, an influential twentieth century psychologist, was known to be the father of psychoanalysis. He was a physiologist who also had interest in anthropology, semiotics, and artistic creativity and appreciation. He is however seen and remembered to be more of a psychology expert.[19] He presented his theory of psychosexual development in Three Essays on the Theory of Sexuality. Freud gave evidence to the fact that in the pregenital phase children do not distinguish between genders or sexes: they assume both parents have the same genitalia and the same reproductive powers. On this basis, he inferred that bisexuality is the original sexual orientation, and that heterosexuality is resultant of repression during the phallic stage, at which point gender identity is ascertainable. According to Freud, during this stage, children develop an Oedipus complex where they have sexual fantasies for the parent ascribed the opposite gender and hatred for the parent ascribed the same gender. This hatred transforms into (unconscious) transference and (conscious) identification with the hated parent who both exemplifies a model to appease sexual impulses and threatens to castrate the child's power to appease sexual impulses.[13] In 1913, Carl Jung proposed the Electra complex as he both believed that bisexuality did not lie at the origin of psychic life, and that Freud did not give adequate description to the female child. This proposal, however, was rejected by Freud.[20]

During the 1950s and '60s, psychologists began studying gender development in young children, partially in an effort to understand the origins of homosexuality (which was viewed as a mental disorder at the time). In 1958, the Gender Identity Research Project was established at the UCLA Medical Center for the study of intersex and transsexuals. Psychoanalyst Robert Stoller generalized many of the findings of the project in his book Sex and Gender: On the Development of Masculinity and Femininity (1968). He is also credited with introducing the term gender identity to the International Psychoanalytic Congress in Stockholm, Sweden in 1963. Behavioral psychologist John Money was also instrumental in the development of early theories of gender identity. His work at Johns Hopkins Medical School's Gender Identity Clinic (established in 1965) popularized an interactionist theory of gender identity, suggesting that, up to a certain age, gender identity is relatively fluid and subject to constant negotiation. His book Man and Woman, Boy and Girl (1972) became widely used as a college textbook, although many of Money's ideas have since been challenged.[21][22]

Medical literature

In late-19th-century medical literature, women who chose not to conform to their expected gender roles were called "inverts", and they were portrayed as having an interest in knowledge and learning, and a "dislike and sometimes incapacity for needlework". During the mid 1900s, doctors pushed for corrective therapy, which meant that gender behaviors that weren't part of the norm would be changed. The aim of this therapy was to push children back to their "correct" gender roles, and thereby limiting the amount of children becoming transgender.[25]

The authors of a 2005 academic paper questioned the classification of gender identity problems as a mental disorder, speculating that certain DSM revisions may have been made on a tit-for-tat basis when certain groups were pushing for the removal of homosexuality as a disorder. This remains controversial,[26] although the vast majority of today's mental health professionals follow and agree with the current DSM classifications.

International Human Rights Law

The Yogyakarta Principles, which is a document on application of international human rights law, provides definition on gender identity. In the preamble, "gender identity" is understood to refer to each person's deeply felt internal and individual experience of gender, which may or may not correspond with the sex assigned at birth, including the person's sense of the body (which may involve, if freely chosen, modification of bodily appearance or function by medical, surgical or other means) and other experience of gender, including dress, speech and mannerism. Further, in Principle 3, that "each person's self-defined gender identity is integral to their personality and is one of the most basic aspects of self-determination, dignity and freedom. No one shall be forced to undergo medical procedures, including sex reassignment surgery, sterilization or hormonal therapy, as a recognition of their gender identity."[27] and in Principle 18, that "Notwithstanding any classifications to the contrary, a person's gender identity are not, in and of themselves, medical conditions are not to be treated, cured or suppressed."[28] Relating to this Principles, "Jurisprudential Annotations to the Yogyakarta Principles" states that "Gender identity differing from that assigned at birth, or socially rejected gender expression, have been treated as a form of mental illness. The pathologization of difference has led to gender-transgressive children and adolescents being confined in psychiatric institutions, and subjected to aversion techniques -including electroshock therapy - as a "cure"".[29] And "Activist's Guide to the Yogyakarta Principles" stresses that "it is important to note that while "sexual orientation" has been declassified as a mental illness in many countries, "gender identity" or "gender identity disorder" often remains in consideration."[30] These Principles influenced the UN declaration on sexual orientation and gender identity.

Present views

Society

The 21st century's generation is the first generation that to varying degrees accepts boys openly playing with and dressing in things normally considered to be for girls. More children are allowed to be in the "middle space” between traditional boyhood and traditional girlhood, with activities and toys from all across the gender spectrum.[25]

Administration

Gender identity and related topics are constantly debated within politics. Recently[when?] in the United States, it was decided under the Affordable Care Act that health insurance exchanges will have the ability to collect demographics regarding gender identity and sexual identity within the affected populations. The questions will be optional, but will help policymakers better recognize the needs of the LGBT community, and prove that the goal is to provide insurance for everyone.[31] The questions are legal, and federal policies promise that nobody will be discriminated against.

Medical field

As of 2014[update], there is some changing of views and new discrepancies about the best way to deal with gender nonconformity. Many members of the medical field, as well as an increasing number of parents, no longer believe in the idea of corrective therapy.[citation needed] Instead, some psychologists and psychiatrists suggest that instead gender neutrality should be encouraged, in which people are not distinguished by their gender.[citation needed] It is believed that this will lead children to be more comfortable with themselves and their feelings. On the other hand, there is still a large number of clinicians who believe that there should be interventions for gender nonconforming children. They believe that stereotypical gender-specific toys and games will encourage children to behave in their traditional gender roles.[25]

Transsexual self-identified people sometimes wish to undergo physical surgery to refashion their primary sexual characteristics, secondary characteristics, or both, because they feel as if they will be more comfortable with different genitalia. This may involve removal of penis, testicles or breasts, or the fashioning of a penis, vagina or breasts. In the past, sex assignment surgery has been performed on infants who are born with ambiguous genitalia. However, current medical opinion is strongly against this procedure, since many adults have regretted that these decisions were made for them at birth. Today, Sex reassignment surgery is performed on people who choose to have this change so that their sexual identity will match their gender identity.[32]

Gender identity and sex

When the gender identity of a person makes them one gender, but their genitals and their body's secondary sex characteristics suggest a different sex, they will likely experience what is called gender dysphoria.[33] Some people do not believe that their gender identity corresponds to the sex they were assigned at birth, including transsexual people, transgender people, and many intersex individuals. Consequently, complications arise when society insists that an individual adopt a manner of social expression (gender role) which is based on sex, that the individual feels is inconsistent with that person's gender identity. Complications can also arise with the stereotyping, or gender typing of behavior for individuals for behavior related to a specific sex, when they identify as a different gender. This dissonance can lead to gender identity disorder.

One reason for such discordances in intersex people is that some individuals have a chromosomal or phenotypical sex that has not been expressed in the external genitalia because of hormonal or other conditions during critical periods in gestation. Such a person may later disagree with a clinical assignment of sex of rearing made at time of birth. The causes of transgenderism are less clear; it has been subject of much speculation, but no psychological theory has ever been proven to apply to even a significant minority of transgender individuals, and theories that assume a sex difference in the brain are relatively new and difficult to prove, because at the moment they require a destructive analysis of inner brain structures, which are quite small.

In recent decades it has become possible to reassign sex surgically. A person who experiences gender dysphoria may then seek these forms of medical intervention to have their physiological sex match their gender identity. Alternatively, some people who experience gender dysphoria retain the genitalia that they were born with (see transsexual for some of the possible reasons), but adopt a gender role that is consistent with what they perceive as their gender identity.

Influencing factors

Biological factors

Some of the research we see today suggests that the development of gender identity is related to genetic or hormonal influences. The biochemical theory of gender identity suggests that we acquire our gender identities through genetic and hormonal factors rather than through socialisation. In the article by Lynda Birke titled “In Pursuit Of Difference, scientific studies of women and men”, it is suggested that sex-determining hormone is produced at the early stage of fetal development. “Ovaries and testes produce hormones,” and “testes produce higher levels of certain hormones (androgen) than do ovaries.” “If the levels of androgens are high, then a penis and scrotum will develop; if they are low, then labia and a clitoris will develop.”[35] When prenatal hormone levels are altered, phenotype progression may be altered as well. Therefore, the natural predisposition of the brain toward one sex may not match the genetic makeup of the fetus, or its external sexual organs. Numerous conditions and variations that have their basis in the prenatal stage can ultimately affect one's gender identity.[36] Possible conditions may result from chromosomal alterations, in which the child doesn't have the normal two chromosomes of XX (female) or XY (male).

In addition to the hormonal influences on gender identity, genes also play a significant role. A gene is "a locatable region of genomic sequence, corresponding to a unit of inheritance found on human chromosomes.[37] For human beings, thousands of genes are inherited from their parents and arranged into 23 pairs of chromosomes. One of them is a pair of sex chromosomes. Females usually have two Xs: so each egg they produce contains one X. Males usually have one X and one Y chromosome, so that each individual sperm can have either an X or a Y chromosome.[38] However, having Y chromosome does not necessarily mean that a person is a male. It is the genes on the Y chromosome that determine whether the human being will have the masculine pathway or not. It is a common mistake when people assume a Y chromosome makes a person a boy or a man and the lack of a Y chromosome makes a person a girl or a woman. For example, one physician educator had the challenging experience of trying to calm a 23-year-old patient who had just been told by a resident that she was “really a man” because the resident had diagnosed the patient as having a Y chromosome and complete androgen insensitivity syndrome (CAIS).[39] As a matter of fact, it is the SRY gene on the tip of the Y chromosome that helps to send the embryo down the masculine pathway. In addition to this gene which is able to turn females in t males, another gene on the X chromosome (the chromosome one typically associates with “femaleness”) called DAX1 when present in double copy in a male (XY), transforms into a female.[39] Thus, gender identity is the summary of the overall genetic makeup and hormones, which provide a blueprint of how the body is supposed to function.

One study conducted by Reiner & Gearhart provides some insight into what can happen when genetically male children are sexually reassigned female and raised as girls. In a sample of 14 children born with cloacal exstrophy and reassigned female at birth, follow-up between the ages of 5 to 12 showed that 8 of them identified as boys, and all of the subjects had at least moderately male-typical attitudes and interests.[40] Similarly David Reimer was born male but after a botched circumcision went through reassignment surgery to become female. Though he always felt like a male and eventually reverted to his original sex.[41] This provides some support for the argument that biological variables have an impact on gender identity and behavior independent of socialization.

Furthermore, evidence suggests that differences in verbal and spatial abilities, memory and aggression are linked to differences in hormone secretions between males and females. In the article by Lynda Birke called “In Pursuit Of Difference, scientific studies of women and men”, it is suggested that human brains and hormone secretions have mutual influence. During the early stage of fetal development, specific hormones will enter the brain and “permanently affect how the hypothalamus works. As before, high levels of hormones known as androgens will stop the hypothalamus from ever organizing hormone cycles. If there are low levels, then it will be cyclic.” This early influence on brain determines the different frequency of hormone secretion later in male or female’s life. “Obviously, women’s sex hormones usually follow a monthly cycle,” while “men’s sex hormones do not follow such a pattern.” [42] This mutual influences between hormones and brains well illustrate the hormonal impact on gender identity.

Some studies have tried to establish a link between biological variables and transgender or transsexual identity, but such studies have been limited and their findings largely uncertain.[43][44] Zhou et al. suggested in 1995 that a sex difference in the central subdivision bed nucleus of the stria terminalis (BSTc) may serve as a biological marker for gender identity, as the volume of BSTc is larger in males than in either females or male-to-female (MtF) transsexual women.[45] Similar brain structure differences have been noted between gay and heterosexual men, and between lesbian and heterosexual women.[46][47] More recent studies have found that circumstance and repeated activities such as meditation modify brain structures in a process called brain plasticity or neuroplasticity. In May 2014, the Proceedings of the National Academy of Sciences reported that for fathers parenting "rewires the male brain".[48]

Other research suggests that the same hormones that allow for differentiation between sex organs in utero also elicit puberty, as well as influence the development of gender identity. Different amounts of these male or female sex hormones within a person will result in varied behavior and external genitalia that do not match up with the norm of the actual sex, and they may instead act and look like the opposite gender.[49]

Social and environmental factors

Gender identity also has a strong correlation to social and environmental factors; such factors would most evidently include the attitudes of the parents raising the child and the culture into which the children are raised. Parents and authoritative figures views on sexuality and gender will have a great influence on children's behaviors, interests, and self-identity. Children learn by observation and reproduction, and will repeat actions and ideas that they see from the adults in their lives; parents who do not support gender nonconformity are more likely to have children with firmer and stricter views on gender identity and gender roles.[49] Even when parents do support gender nonconformity, many will usually only support it to a point, though recent literature suggests a trend towards less well-defined gender roles and identities as studies of parental coding of toys as masculine, feminine, or neutral indicate that parents are increasingly coding kitchens and in some cases dolls as neutral rather than exclusively feminine.[50] Despite this, however, it was more common in Emily Kane’s research for parents to show negative responses to items, activities, or attributes that could be considered icons of femininity, and research has indicated clearly that many parents are working to accomplish gender with and for their sons is in a manner that distances those sons from any association with femininity. Somewhat conversely, it emerged in Kane’s research that the connection between gender performance and sexual orientation was not spontaneously raised for daughters - parents did not bring up concern for their girls being considered homosexual as a result of identifying with masculine qualities as they did when considering their sons' identifying with feminine qualities. Traditional attributes and abilities of femininity such as domestic skills, nurturance, and empathy were particularly seen as cause for concern by parents, suggesting that gender conformity and heterosexuality are closely linked with hegemonic constructions of masculinity.[50]

The environment in which a child is raised in regards to gender is created before the child is even born. Current technology, such as ultrasound, allows parents to determine the biological sex of the child before birth and to alter their preparation for the child accordingly. A child will thus typically arrive to a decided gender-specific name, games, and even ambitions.[36] When the child's sex is determined, most children are raised to be a man or a woman, with the related social roles based on the parents' beliefs. Sociologist LaFreniere states, "By the time children are 3 to 4 years old, they have already formed an image of themselves as boy or girl."[51] According to Emily Kane, “children themselves become active participants in this gendering process by the time they are conscious of the social relevance of gender, typically before the age of two".[50] Children form these thoughts through parents, teachers, peers, and the games and toys that they play with at a young age. Sociologist Doob states that by the age of five, girls show a preference for dolls, doll accessories, drawing, painting, and soft toys while boys will tend to prefer blocks, small vehicles, tools and rough-house play.[52] Many parents invoke biology in explaining their children’s gendered tendencies, though in reality children are going to act in ways that receive a positive response from their parents and will change their behavior accordingly if given a negative response, meaning that, as Kane's research has found, “the parental boundary maintenance work evident for sons represents a crucial obstacle limiting boys options, separating boys from girls, devaluing activities marked as feminine for both boys and girls, and thus bolstering gender inequality and heteronormativity.”[50]

Balancing gender roles and identity is not easy, and identity work is not something that just ends once one identifies as masculine or feminine; gender identity work is done throughout one’s life. Studies have deemed identity work successful if individuals manage to craft identities that sustain their self-esteem and grant them social validation in their roles.[53] One area where gendered identity work is prevalent is in career transitions. Identity work is gendered during a work transition in three ways. These ways are, the culturally available master narrative of career change are heroic stories, some interviewees adopt gendered identity positioning in accounting for the need to change careers, and identity work results in struggles between conflicting identity positions that may be gendered.[54] By heroic stories, it is meant that position as a career changer serves identity work in legitimizing unwanted career problems and strengthening identity, whether a change is made or not. This means that talk about career change is a way of moving from a victim position and adopting a temporary position as an active and heroic career actor.[54] Adopting gendered identity positioning to account for the need of a career change can happen when the reason for not being able to feel authentic at work may be due to gender. The role of gender in the timing of the transition also applies to life renewal narratives, where the transition is explained by changes in personal life. In these cases, the narrator has been content with a past career but the need for career development has emerged due to a divorce, age crisis, or children growing up.[54] Finally, the struggle between conflicting identity positions may invoke negotiation between an identity position in which one has been place and a newly desired one or between two desired but incompatible positions.[54] An example of this would be becoming a student at an older age in order to become self-sufficient but while in school you are at the mercy of your spouse financially. These are two conflicting identities but can sometimes account for the transition that also fuels an identity struggle.[54] This struggle results from differing concepts of a good career and life that the identity positions encompass [54] When learning about the social construction of gender identity work, it is important though to remember that “the way in which identity work can be done and how it’s resources are gendered is dependent on the particular cultural context.”[54] This means that it is necessary to take in the cultural context of the individual when studying or looking at gender identity work.

Nature vs. nurture

The extent to which gender identity is determined by socialization (environmental factors) versus in-born (biological) factors is an ongoing debate in psychology, known as nature versus nurture. While gender roles and sex differences are both largely recognized as influential in behavior, it is often difficult to determine the separate impacts of socialization and genetic variables.

Although there may be discrepancies as to which factor plays the most important role, there is extensive agreement that a combination of many different views and perspectives are needed for a complete understanding of gender development.

The idea of nature versus nurture has had quite an effect on gender identity. Nature has to do with the hormonal aspect and the genetic make up. Certain genetic variations may produce gender-variant identities. Gender identity development has genetic influence (Dragowski). The second aspect is nurture, which has to do with environmental aspects and parental influence of genetic identity. Parents are the ones who create the values and behaviors that their children create. Most parents tend to surround their children with gender-typed toys and clothes. One of the most known examples of nature verses nurture was the case of David Reimer, otherwise known as “John/Joan”. As a baby, David went through a faulty circumcision, losing his male genitalia and from then on he was designed to be a girl. Psychologist John Money convinced Reimer’s parents to raise David as a girl. Reimer grew up as a girl dressing in girl clothes and was surrounded by girl toys, but he still felt as though something was wrong. David did not feel like a girl and after trying to commit suicide by age 13, Reimer was then told he was born a boy. Once he was told the truth, he immediately went into surgery to get the proper genitalia back. This went against Money’s idea that biology had nothing to do with gender identity or human sexual orientation.[55]

Non-Western gender identities

Fa'afafine

In some Polynesian societies, fa'afafine are considered to be a "third gender" alongside male and female. They are biologically male, but dress and behave in a manner considered typically female. According to Tamasailau Sua'ali'i (see references), fa'afafine in Samoa at least are often physiologically unable to reproduce. Fa'afafine are accepted as a natural gender, and neither looked down upon nor discriminated against.[56] Fa'afafine also reinforce their femininity with the fact that they are only attracted to and receive sexual attention from straight masculine men. They have been and generally still are initially identified in terms of labour preferences, as they perform typically feminine household tasks.[57] The Samoan Prime Minister is patron of the Samoa Fa'afafine Association.[58] Translated literally, fa'afafine means "in the manner of a woman."[59]

Hijra

In some cultures of Asia, a hijra is usually considered to be neither a man nor a woman. Most are biologically male or intersex, but some are biologically female. The hijra form a third gender, although they do not enjoy the same acceptance and respect as males and females in their cultures. They can run their own households, and their occupations are singing and dancing, working as cooks or servants, sometimes prostitutes, or long-term sexual partners with men. Hijras can be compared to transvestites or drag queens of contemporary western culture.[60] In July 2012 gender activist Gopi Shankar coined the regional terms for genderqueer people in Tamil. Gopi said that apart from male and female, there are more than 20 types of genders, including trans woman, trans man, androgynous, pangender, trigender, and ancient India refers it as Trithiya prakirthi. After English, Tamil is the only language that has been given names for all the genders identified so far.[61][62][63]

Khanith

The khanith form an accepted third gender in Oman, a gender-segregated society. The khanith are malehomosexualprostitutes whose dressing is male, featuring pastel colors (rather than white, worn by men), but their mannerisms female. Khanith can mingle with women, and they often do at weddings or other formal events. Khaniths have their own households, performing all tasks (both male and female). However, similarly to men in their society, khaniths can marry women, proving their masculinity by consummating the marriage. Should a divorce or death take place, these men can revert to their status as khaniths at the next wedding.[64]

^ ab"The term 'gender identity' was used in a press release, November 21, 1966, to announce the new clinic for transsexuals at The Johns Hopkins Hospital. It was disseminated in the media worldwide, and soon entered the vernacular. ... gender identity is your own sense or conviction of maleness or femaleness." Money, John (1994). "'The concept of gender identity disorder in childhood and adolescence after 39 years'". Journal of Sex and Marital Therapy20 (3): 163–77. doi:10.1080/00926239408403428. PMID7996589.